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Reducing Exposure to Environmental
Toxicants Before Birth: Moving from
Risk Perception to Risk Reduction
Holly A. Grason, MAa,b
Dawn P. Misra, PhDb,c
SYNOPSIS
In this study, we considered approaches to reducing maternal exposure to
hazardous environmental toxicants, focusing on risk communication to pregnant
women and providers, but also considering identification of environmental
toxicants in the community and reduction of environmental toxicants. We
addressed the following questions: (1) What do pregnant women and their
providers know about environmental toxicants and perinatal health? and (2)
What policy strategies are needed (should be considered) to move forward in
risk reduction in this area? We reviewed the literature on knowledge of pregnant women and providers regarding these issues.
While there is limited research on what pregnant women and their providers
know about environmental toxicants and perinatal health, there is evidence of
reproductive and perinatal toxicity. This article describes a wide range of policy
strategies that could be implemented to address environmental toxicants in the
context of perinatal health. Effective leadership in this area will likely require
collaboration of both environmental health and maternal and child health leaders and organizations.
Department of Population and Family Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
a
Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI
b
Women’s and Children’s Health Policy Center, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
c
Address correspondence to: Dawn P. Misra, PhD, Division of Epidemiology and Biostatistics, Department of Family Medicine and Public
Health Sciences, Wayne State University School of Medicine, 101 E. Alexandrine, Room 203, Detroit, MI 48201; tel. 313-577-8199; fax
313-577-3070; e-mail <[email protected]>.
©2009 Association of Schools of Public Health
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Evidence of the negative impact of environmental
toxicants on human health is on the rise. While early
work largely considered the effects of pollutants on
cardiovascular, pulmonary, and cancer disorders
among adults, it is now clear that exposures in utero
and during childhood may be even more hazardous,
with wider-ranging effects.1,2 First, fetuses, infants, and
children undergo rapid growth and development as
compared with adults. The higher rate of cell division and differentiation may increase susceptibility
to adverse effects of exposures and experiences with
exposures during critical development periods, leading to permanent structural and/or organ system deficits.3,4 Second, the fetus may be exposed even when
the mother appears to be unexposed. For example,
environmental toxicant exposures, such as polychlorinated biphenyls and lead, persist in body tissues and
thereby expose a fetus even after maternal exposure
is eliminated.5,6 Finally, exposures during early life
could permanently affect reproductive tract structures
and harm the next generation (e.g., mechanism of
action for diethylstilbestrol).
A wide range of environmental toxicants has
been implicated as hazards across the reproductive
continuum, from conception to birth. The study of
reproductive and perinatal environmental hazards is
rapidly evolving and apparently conflicting results have
been reported. This requires us to not only evaluate
the evidence of what is hazardous, but also to examine what can and should be done about it. Effectively
addressing environmental toxicants in the context of
perinatal health will likely require ongoing collaborative scholarship, leadership, and advocacy from both
the fields of environmental health (EH) and maternal
and child health (MCH).
Three general approaches can be taken to reduce
exposure to environmental toxicants. First, the toxicant source could be targeted. This would include,
for example, strengthening regulatory components
of the Clean Air Act or developing new technologies
to further improve water quality so that exposures
are diminished or eliminated. A second approach
involves the up-to-date identification of environmental
toxicants present in our communities. Primarily, this
relates to methods of reporting chronic exposures,
with the intent that exposure will be reduced either by
avoiding the exposure, through community clean-up
activities, or both. A third approach is risk communication to women and their providers. This is necessarily
intertwined with risk identification, as women’s and
provider’s knowledge of the link between exposure and
outcomes may not lead to a reduction in exposure if
the presence of the exposure is not publicized.
In this article, we address the following questions:
(1) What do pregnant women and their providers know
about environmental toxicants and perinatal health?
and (2) What policy strategies are needed to move
forward in risk reduction in this area?
BACKGROUND
Impact of environmental toxicants on reproductive
and perinatal outcomes
Environmental toxicants with the potential for harming
reproductive or perinatal health are numerous. For
many toxicants, there is as yet little empirical human
data to demonstrate adverse effects, and risk communication on those factors is either minimal or absent.
The literature on health outcomes categorizes the most
studied toxicants in the arena of human reproductive/
perinatal health as: air pollution,7–17 heavy metals (e.g.,
lead),18–22 mercury,23–27 arsenic,28,29 and pesticides.30–40
While there are a number of methodologic challenges
to studying these exposures and birth outcomes, and
results have been somewhat mixed, there is evidence
that these toxicants may increase risks of low birthweight, intrauterine growth restriction, preterm birth,
and birth defects. A growing literature on emerging
chemicals of concern indicates that the toxicants
most frequently investigated, both due to concerns
of toxicity and their seemingly ubiquitous nature, are
endocrine disruptors, including bisphenyl A, phalates,
and perchlorates.41,42
While debate persists regarding the existence
and/or magnitude of exposure thresholds at which
individual environmental toxicants may cause harm
to reproductive and perinatal health, we argue that it
is necessary to investigate what consumers (primarily
pregnant women, but also women generally) and providers believe and do about exposure to these toxicants.
In many cases, there may be no individual-level benefit
against which to balance exposure (e.g., air pollutant),
leading to advocacy for reducing exposures regardless
of the level of scientific proof of causation. There may
be benefits associated with other toxicants, however,
necessitating a risk analysis. This is clearly an issue with
regard to fish consumption. Eating fish may expose
women to mercury, a toxicant potentially hazardous
at any level to the developing fetus,23 and at the same
time provide fatty acids that may promote healthy brain
development in the fetus. We argue that leadership is
critical when knowledge is uncertain.
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Reducing Exposure to Environmental Toxicants Before Birth  631
What do pregnant women know and
do about environmental toxicants?
Overview
Little empirical data on knowledge about environmental toxicants have been reported with regard to
either women or their providers. Data collected by
the Organization of Teratology Information Services
(OTIS) hint at the interest and knowledge level in this
regard. OTIS is a private nonprofit organization with
specialized teratology information centers covering 24
states, a regionalized telephone consulting service via
a toll-free number (866-626-OTIS), and a website with
fact sheets (www.otispregnancy.org). One can glean
from OTIS caller data that a nascent level of awareness
exists among the general public. For example, OTIS
2003–2004 survey data reveal the types of exposures
queried from more than 70,000 annual inquiries: 4%
maternal illness, 8% environmental agents, 3% radiation, 17% occupational agents, 4% herbal products,
6% drugs of abuse, and 58% medications. In addition,
they show that 74% of calls were related specifically to
pregnant women, 9% to preconceptional concerns,
and 8% to breastfeeding.43
Few published studies reveal where women seek
health information generally,44–47 and none address concerns regarding reproductive and/or perinatal environmental or occupational toxic exposures. There is broad
variation in information-seeking behavior, presumably
by gender, age, and other sociodemographic factors,
with respect to the full range of sources—­broadcast
media, organized health events, billboards, print
news media, magazines, computer-based resources,
friends, families, and clinicians. Figure 1 highlights
information sources identified in a systematic search of
online materials conducted between June and August
2007, using the search terms “pregnancy,” “pregnant
women,” “reproductive health,” “environmental exposures,” “environmental hazards,” and “environmental
toxins.”48
Information sources also exist that women (and
their providers) might use to learn about potential
environmental hazards at work and at home. The
federal government hosts a number of technical websites. However, two federally funded websites operated
by nonprofit organizations are particularly accessible.
Community Right to Know (www.crtk.org/index.cfm)
provides links for accessing information about local
environmental hazards/conditions, environmental
legislation, and toolboxes for community organizing.
SCORECARD (www.scorecard.org) allows a zip codebased search of local environmental conditions, air
and water quality, and location of pollution sites. The
website also includes fact sheets on a wide variety of
chemicals and exposures—indexed by type of health
risk posed (including developmental and reproductive
toxicants)—and links to federal regulations regarding
health and environmental exposures.
Environmental toxicants
Despite a rigorous and broad search of Medline and
the Internet (using broad search terms and iterative
combinations, e.g., environment, environmental,
toxicants, pollutants, pollution with pregnancy, perinatal, prenatal, maternal, and reproductive), we did
not identify any peer-reviewed articles on pregnant
women’s knowledge and behaviors regarding multiple
environmental toxicants and childbearing. This was
in contrast to a substantial literature on exposure to
toxicants and reproductive/perinatal health. The few
published studies that have examined knowledge of
hazardous environmental toxicants and childbearing
considered only the issue of mercury exposure from
fish. First, an article by Frey et al. examined women’s
knowledge prior to conception for a wide range of topics, but the only environmental topic considered was
consumption of certain fish. Slightly more than half
of women reported knowledge of the risks associated
with such consumption. This was in marked contrast
to women’s knowledge of factors such as smoking and
alcohol use, for which $95% of women were aware of
the potential dangers.49 However, this study did not test
the accuracy of women’s knowledge (e.g., which fish
and what amounts pose a hazard).
A recent 12-state study of women of childbearing
age focused on fish consumption generally (not within
the context of pregnancy), understanding of mercury
toxicity, and awareness of advisories regarding fish
consumption. Only 20% of women reported being
aware of state advisories on sport fish consumption.
The majority (71%) of women were aware that mercury
harms the developing fetus, with knowledge more likely
among women who reported being aware of the advisories (87% vs. 67%).50 Second, in the only published
study with data presented that were specific, pregnant,
low-income pregnant, and breastfeeding women in a
California Women, Infants and Children clinic were
surveyed regarding knowledge of fish advisories and
mercury. Approximately 45% of women were aware
that health warnings had been issued for consumption
of fish and shellfish in women of childbearing age,
and only 31% of all women (more than two-thirds of
those with any awareness) had specific awareness of
the advisory content. Levels of awareness were slightly
higher for pregnant women.51
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Figure 1. Information resources for reproductive-age women and their health-care providers
Source
Available information
Organization of Teratology Information
Specialists (OTIS)
www.otispregnancy.org
Fact sheets in English and Spanish on a variety of common exposures
Links to OTIS information centers for both health professionals and individuals
March of Dimes Birth Defects
Foundation
www.marchofdimes.com/pnhec/159.asp
Fact sheets, brochures, and a screening checklist
Motherisk
www.motherisk.org
Telephone helplines to answer women’s questions about pregnancy, including exposures
Links to peer-reviewed articles about environmental exposures and child health
E-Learning Center for health-care professionals with video tutorials on teratology
American College of Obstetricians and
Gynecologists
www.acog.org/publications/patient_education
Brochure on good health before pregnancy, including environmental exposures
What to Expect
www.whattoexpect.com/pregnancy/work-issues/health-and-safety.aspx
Basic information about common exposures, particularly in the workplace
Includes message boards and blogs for women to post and respond to questions
Women’s Voices for the Earth
www.womenandenvironment.org
Grassroots environmental health and justice organization
Reports and fact sheets with specific information on risks of household cleaning products
and exposures (e.g., mercury during pregnancy)
Awareness campaigns and community events
Office of Women’s Health, U.S.
Department of Health and Human
Services (HHS)
www.4woman.gov
Fact sheets on mercury and medications, “Fish Facts Print and Go Guide,” and “Food
Don’ts Print and Go Guide”
General information on the environment and women’s health
General information about preconception, pregnancy, and overall health
Agency for Toxic Substances and
Disease Registry, Centers for Disease
Control and Prevention (CDC), HHS
www.atsdr.cdc.gov
Complex and comprehensive information about toxic substances; little specific information
is oriented to reproductive health
Food and Drug Administration, HHS
www.fda.gov/womens/healthinformation/pregnancy.html
Fact sheets on pregnancy and medicines, infections, and food safety, including mercury
and fish. Site allows users to research the safety and effectiveness of various medications
that might be used during pregnancy.
National Institute of Environmental
Health Sciences (NIEHS), HHS
www.niehs.nih.gov
Links to NIEHS studies regarding reproductive health
Specific information can be found at http://www.niehs.nih.gov/oc/factsheets/pregnant/
home.htm
Offers comprehensive information about environmental influences on the development
and progression of human disease; limited information about reproductive health is
available
National Institute of Occupational
Safety and Health (NIOSH), National
Occupational Research Agenda, Fertility
and Pregnancy Abnormalities Team,
CDC, HHS
www.cdc.gov/niosh
NIOSH conducts research and makes recommendations about the prevention of workrelated injury and illness; geared toward professionals and employers. Specific information
about reproductive health includes general safety and health issues at work for pregnant
women.
continued on p. 633
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Reducing Exposure to Environmental Toxicants Before Birth  633
Figure
resources
for reproductive-age
and their providers
health-care providers
Figure 1
1. (continued).
Information Information
resources for
reproductive-age
women and women
their health-care
Source
Available information
Occupational Safety and Health
Administration (OSHA)
www.osha.gov
Offers complex, comprehensive information about workplace safety and health; geared
toward employers. Website includes a link to information specifically about OSHA’s
standards regarding reproductive hazards.
National Library of Medicine
www.toxtown.nlm.nih.gov
ToxTown website includes interactive tool for the general public to learn about toxic
chemical and environmental health risks. Some information included about risks to
pregnant women.
More technically oriented sites include:
National Library of Medicine: Household Product Database: www.hpd.nlm.nih.gov
National Library of Medicine: MedlinePlus: www.nlm.nih.gov/medlineplus/
poisoningtoxicologyenvironmentalhealth.html
National Library of Medicine: TOXNET: www.toxnet.nlm.nih.gov
Broadly expanding our Internet search with regard
to any environmental toxicants, we identified a few
unpublished reports relevant to this topic focusing on
risk communication interventions. However, these studies were limited to fish contamination. The Adult Food
Stamp Nutrition Education Fish Connection program
in California targeted women who could become or
were pregnant, as well as mothers. Participants demonstrated increased knowledge and changes in consumption with regard to mercury-containing fish after four
classes. Some broad-based efforts do not specifically
target pregnant women or women of childbearing
age. One example is the Fish Contamination Education Collaborative, an outreach and education project
supported by the Environmental Protection Agency
(EPA). While the activities were broad, they assessed
knowledge, attitudes, and beliefs among women of
childbearing age of different ethnicities, comparing
baseline to follow-up.52 The study found an increase
in awareness of fish advisories and in beliefs about the
importance of fish advisories related to health issues
generally (not specific to pregnancy).
Occupational toxicants
As many of the environmental toxicants are also prevalent in occupational settings, we searched for literature
on occupational exposures and pregnancy with regard
to women’s knowledge and actions, but found no
reported or published journal articles providing empirical data. We then specifically investigated whether
occupational health regulations had been evaluated
with regard to reproductive and perinatal health.
The Occupational Safety and Health Act promulgated
the Hazard Communication Standard in 1983, with
mandated evaluation of health hazards, labeling of
containers, use of material safety data sheets (MSDSs),
and employee training to ensure information uptake.
In 1991, the Government Accounting Office conducted
a study of regulatory action in this arena, finding current federal efforts inadequate.53 Recommendations
included more comprehensive and specific review of
toxicity data, separate analyses for reproductive and
developmental outcomes in risk assessment, and more
data and information for decision-makers and the
media. We found no evaluations of the Hazard Communication Standard in the published literature prior
to 1990, and few since. Regarding hazards to reproductive health, in the late 1980s, only 53% of the MSDSs
in Massachusetts noted the potential effects of lead and
ethylene glycol ethers on reproductive health.54
Beyond processes to meet federal information and
safety training mandates, employers may offer occupational health services that are of potential use to
women who may be concerned about toxic exposures.
Frazier and colleagues reported on the experiences of
women presenting to an occupational health service’s
reproductive hazards consultation service.55 Eighty
percent of the women using the service were already
pregnant and working, with a mean of 15.5 chemical
exposures classified as reproductive hazards.
What do providers know and do
about environmental toxicants?
Overview
Data on provider knowledge and behavior are as scarce
as that for women. In a recent article on preconceptional factors and occupational/environmental factors,
McDiarmid and Gehle speculated that women may have
more interest and knowledge than providers.56 The lack
of current baseline information on provider knowledge
and behavior means that efforts to address these issues
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with providers are difficult to evaluate. While directly
targeting women may have effects on their exposure,
knowledgeable providers who disseminate information to patients may have an even greater alternative
or complementary effect. Educated providers could
initiate conversations about environmental toxicants or
act to reinforce women’s own knowledge. For example,
drawing on literature relating to maternal smoking,
studies suggest that educating providers may be more
effective in changing women’s behavior than directly
targeting women to quit.57,58
Dissemination of knowledge, however, is not the
only role providers can play, and it may not even be the
primary role that is needed regarding environmental
toxicants and reproductive/perinatal health. Education of clinicians could lead to increased assessment
and identification of women with regard to hazardous
environmental toxicants, more accurate estimation of
the risk associated with such exposures, communication
of risk estimates to women, and appropriate referral
of women to specialty care and resources.
There appears to be general consensus that clinicians are not well-versed on the subject of environmental exposures. In 1988, the Institute of Medicine examined the role of primary care physicians in occupational
and environmental medicine and called for enhanced
physician training and education, stating, “. . . as a
minimum, all primary care physicians should be able
to identify possible occupationally or environmentally
induced conditions and make the appropriate referrals
for follow-up.”59 We found only one study examining
environmental medicine content in medical school
curricula. With nearly all of the accredited U.S. medical schools responding to the survey, 76% indicated
inclusion of environmental content, with a mean of
seven hours of instruction on this content.60
Clearly, education for clinicians occurs along a continuum, undertaken in the context of residency training and continuing education. The materials described
in Figure 2 are those found in our searches.
Considerations concerning risk reduction strategies
Our exploration of risk communication regarding
environmental hazard risks to reproductive/perinatal
health uncovered a set of policy and practice initiatives that were germane and potentially instructive of
future directions. We observed that policy tools and
practice knowledge are available in the broadest sense,
but nearly all lack a concerted focus on the populations and health concerns at hand. Moreover, those
focused efforts that do exist are relatively recent and
understudied. These strategies can be conceptualized
as being along a continuum from risk perception to
risk reduction, and along a continuum from the individual level to the population level. Figure 3 shows a
brief synopsis of this set of strategies.
Figure 2. Sources of provider education specific to pregnancy and environmental hazards
• Pope AM, Rall DA, editors. Environmental medicine: integrating a missing element into medical education. Washington: National
Academy Press; 1995.
This text can be used to integrate material into medical school curriculum; it has four appendices with 55 case studies, and also
educational resources and teaching aids. The topic of Case Study #53 is reproductive and developmental hazards.
• Frazier LM. Workplace reproductive problems. Primary Care: Clinics in Office Practice 2000;27:1039-55.
Written for practicing primary care physicians, this article includes an overview of hazards and specific advice about screening,
assessment, counseling, and possible actions that the physician can take to assist his/her patient.
• Hoskins IA. Environmental and occupational hazards to pregnancy. Primary Care Update for OB/GYNS 2003;10:253-7.
This article offers a brief synthesis of new science.
• Agency for Toxic Substances and Disease Registry. Case studies in environmental medicine [cited 2009 Mar 24]. Available from:
URL: http://www.atsdr.cdc.gov/csem/csem.html
This Web-based series of self-instructional publications is designed to increase primary care providers’ knowledge of hazardous
substances in the environment. The continuing education course, “Taking an Exposure History,” was updated in 2000 and is the
most relevant of the set to perinatal health.
• Association of Occupational and Environmental Clinics (AOEC). Peer-reviewed modules [cited 2009 Mar 25]. Available from:
URL: http://www.aoec.org/resources.htm
Educational resources are posted on the AOEC website.
• Journal of Midwifery and Women’s Health 2006, Volume 51, Number 1
This supplemental issue includes an editorial, feature articles on toxins, a case study of screening for pesticide exposure, and an
article on information sources. The issue also includes a tear-out fact sheet to give to patients. The supplement is part of the selfstudy continuing medical education series of the American College of Nurse-Midwives (ACNM) and is accessible on the ACNM
website (http://www.midwife.org).
Public Health Reports / September–October 2009 / Volume 124
News releases, information posting
on governmental and nonprofit
organization websites, posting of
notices in public places
Print, television, and radio news
features produced nationally,
regionally, and locally
Laws requiring labeling of risks of
toxic exposure for a wide assortment
of specific chemicals, including
pesticides
Bans on smoking in public places,
such as worksites and restaurants
American College of Obstetricians
and Gynecologists standard
environmental history form includes
smoking, alcohol, and drug use.
More recently, clinician querying
about fish consumption and/
or residential proximity to known
pollution sources encouraged by
professional groupsf
Mass media
Product labeling
Legislation/regulation
Health provider
counseling
What exists
Public notification
Strategies
Public Health Reports / September–October 2009 / Volume 124
Limited education of women’s health clinicians in specific regard to
environmental exposuresi
Practice constraints; limited time for counseling
Some exposures are difficult for women to self-identify
Timing of information vs. timing of exposure; can be too late to make a
preventative difference
Women known to seek and trust
information from their health-care
providersg,h
continued on p. 636
Political process of legislation and regulation can be complex and
protracted
Can be difficult to craft appropriate messages when substance may have
both risks and benefits (e.g., fish)
May be inaccessible to some with limited reading ability and language
barriers
Can be general in nature without translation to issues related to
reproductive health
Selection of topics covered not systematic
Quality control is absent; potential for “unscientific” sensationalism
Most often general in nature, without translation to issues of
reproductive risks
Questions regarding whether notification laws incorporate sufficient
range of chemicals, industries, and sitesa
Emphasis on specific areas related less to science than to context of
individual behavior change
Content of information not easily controlled; varies widely with
respect to accessibility, the nature and scope of content, differing and
unspecified audiences, and technical complexity
May be inaccessible to some with limited reading ability and language
barriers
Limitations
Substantial reduction in
environmental tobacco smoke
exposuree
Content of information can be
controlled, consistent
Some documentation of
effectiveness of labeling with
respect to alcohol and smoking in
pregnancyc,d
Some documented effectiveness
in knowledge improvementb
Potential to reach a broad and
diverse audience
Required in legislation for many
known hazardous substances;
structures and resources in place
Potentially broad reach,
particularly with regard to the
Internet
Strengths
Figure 3. Environmental toxins risk reduction strategies for perinatal health
Reducing Exposure to Environmental Toxicants Before Birth  635
Systematic surveillance available for
many reproductive and perinatal
outcomes, such as low birthweight
and birth defects
EPA report, “America’s Children
and the Environment,”k includes
quantitative information for trends
related to levels of environmental
contaminants in air, water, food,
and soil, and concentrations of
contaminants measured in children
and women
Some local health agency efforts to
monitor, for example, blood mercury
levels among specific population
subgroupsl
Surveillance
Can be expensive; requires public funding
Currently not coordinated efforts with respect to lifespan approach;
address pediatric and reproductive/perinatal foci independently
Uneven geographic coverage
Limited and uneven quality monitoring of spontaneous and induced
abortions as well as infertility
Uneven monitoring of exposures and outcomes at the local level
hampers pinpointing of potential hot spots
Number of toxicants examined
and frequency of measurement
for the maternal and child health
population increased in recent
years
National Children’s Study
(longitudinal) launched
Limitations
Information provided by scientific
experts; assume high degree of
accuracy. Appropriate translation
of specific risks likely
With sufficient outreach, can be
broadly recognizable and wellusedj
Strengths
Hankin JR. Fetal alcohol syndrome prevention research. Alcohol Res Health 2002;26:58-65.
Lumley J, Oliver S, Chamberlain C, Oakley L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2004;4:CD001055.
l
McKelvey W, Gwynn RC, Jeffery N, Kass D, Thorpe LE, Garg RK, et al. A biomonitoring study of lead, cadmium, and mercury in the blood of New York City adults. Environ Health Perspect
2007;115:1435-41.
k
Woodruff TJ, Axelrad DA, Kyle AD, Nweke O, Miller GG. America’s children and the environment: measures of contaminants, body burdens, and illnesses. Washington: Environmental
Protection Agency (US); 2003. Also available from: URL: http://www.epa.gov/envirohealth/children/index.htm [cited 2009 Mar 31].
j
Institute of Medicine, Board on Health Promotion and Disease Prevention. Forging a poison prevention and control system. Washington: National Academies Press; 2004.
i
Schenk M, Popp SM, Neale AV, Demers RY. Environmental medicine content in medical school curricula. Acad Med 1996;71:499-501.
h
Melvin C, Gaffney C. Treating nicotine use and dependence of pregnant and parenting smokers: an update. Nicotine Tob Res 2004;6 Suppl 2:S107-24.
g
f
McDiarmid MA, Gehle K. Preconception brief: occupational/environmental exposures. Matern Child Health J 2006;10(5 Suppl):S123-8.
e
Repace JL, Hyde JN, Brugge D. Air pollution in Boston bars before and after a smoking ban. BMC Public Health 2006;6:266.
d
c
Hammond D, McDonald PW, Fong GT, Brown KS, Cameron R. The impact of cigarette warning labels and smoke-free bylaws on smoking cessation: evidence from former smokers. Can J
Public Health 2004;95:201-4.
b
Food Safety and Inspection Service, Department of Agriculture (US). PR/HACCP rule evaluation report. Changes in consumer knowledge, behavior, and confidence since the 1996 PR/
HACCP final rule. 2002.
O’Neil SG. Superfund: evaluating the impact of executive order 12898. Environ Health Perspect 2007;115:1087-93.
a
10 Environmental Protection
Agency (EPA)-sponsored pediatric
environmental health specialty units
17 Organization of Teratology
Information Services programs
What exists
Specialized resource
centers
Strategies
3. (continued).
Environmental
toxins risk reduction
perinatalfor
health
Figure 3
Environmental
toxins riskstrategies
reductionfor
strategies
perinatal health
636  Viewpoint
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Reducing Exposure to Environmental Toxicants Before Birth  637
Potential Future Policy Directions
Exposure of reproductive-age women to environmental
toxins is an issue of national leadership and commitment. As an initial step, better management of information, including information vehicles, is needed. While
perhaps not satisfying all constituencies, the current
efforts of federal agencies and national nonprofit
groups focused on environmental and occupational
toxic exposures are noteworthy. Environmental science is slowly coming to the attention of public and
private sector professionals concerned with MCH, but
there is room for improvement. Organizational, as well
as communication and behavior change aspects will
clearly be important components, but effectiveness in
these arenas remains uncertain with respect to a wide
range of interventions.
While prenatal influences are important to consider, the earliest time periods—the periods prior to
conception (preconceptional), not just prior to birth
(prenatal)—demand greater attention. First, exposure
during the preconceptional period may persist in body
tissues (e.g., lead). Second, exposures in early life could
permanently affect reproductive tract structures (e.g.,
diethylbestrol). Third, women may be unaware of pregnancy during the early period, when the fetus is most
vulnerable to malformations and loss. Furthermore,
this knowledge is likely influenced by demographic and
psychosocial risk factors, so that women with the highest risk are the least likely to learn of their pregnancy
early. Finally, even if women know they are pregnant,
they may not be able to initiate prenatal care during
this early period and receive information, as clinicians
may not see women until 10–12 weeks gestation.
Therefore, we suggest adoption of a life course
approach to this problem, which should lead to an
expansion of education efforts and presumably not
to a dilution of the message. For example, risk communication efforts need to target providers beyond
obstetricians/gynecologists and midwives. Ways to
reach nonpregnant women with these messages need
to be developed. We must ensure that a one-size-fits-all
strategy does not evolve as a result of shifting to a life
course approach.
To date, more focus (and action) has been given to
child health, with a concomitant lack of attention and
resources given to environmental toxicant exposures
during the preconceptional and pregnancy periods.
Even if the goal remained to improve children’s
health, it is clear that exposures to children’s mothers (and fathers) prenatally and even prior to conception may have a lifelong impact on the child. To
truly protect children from environmental toxicants,
we need to expand beyond a narrow conceptualiza-
tion of ­children’s EH and consider exposures during
these earliest time periods. The recent investment
in the National Children’s Study affirms the interest
of researchers and policy makers in investigating the
potential lifelong effects of prenatal exposures on
childhood and adult health.
Another foundational area is in the field of risk
communication. Risk perception plays a central role in
risk communication strategies. Bennett compiled a list
of “fright factors” that may lead to perception of risks
as “more worrying and less acceptable.” Nearly all of
these factors apply to the issue of environmental toxicants and reproductive/perinatal health, suggesting
that risks might be perceived as more alarming for this
topic than for others. What little is known specifically
about risk perception by women regarding pregnancy
suggests that there are factors resulting in overestimation of risk.61–64 The findings of these studies highlight
the very charged context of pregnancy with regard to
risk communication, a factor we must consider as we
seek to inform women of risks of exposures that may
be difficult to prevent. It is clear that we are far from
a complete understanding of how women perceive risk
during pregnancy—an important domain to master to
develop effective risk communication about potential
hazards, such as environmental toxicants.
Our review of environmental risk communication in
relation to perinatal outcomes suggests, then, a number
of potential next steps for concerned professionals
and government agencies. We believe that there are
several straightforward and low-cost actions that can
be taken in the short term. In addition, our analysis
points to both a need and an opportunity to reduce
environmental hazard exposures preconceptionally
and in the pregnancy period over the longer term.
Feasible short-term actions
Capitalize on public notification requirements that stem
from environmental legislation. Government agencies
can work together and with their nonprofit partners to
further enhance their websites and print materials by
organizing available information. Technological tools,
such as links to local environmental data on existing
websites, could serve as a model and means for making
perinatal health-related information more accessible to
women and health-care providers. This would further
require some translation of the scientific data and
related information for general public audiences, as
well as efforts to address culture and language-specific
targeting concerns.
Continue and enhance use of the news media. As noted,
mass media can be influential and already has
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638  Viewpoint
­ emonstrated an interest and commitment to report
d
on environmental issues. Partnerships exist in other
arenas of health care wherein journalists convene for
education on selected topics (e.g., Journalism Fellowships in Child and Family Policy and the Knight
Center for Specialized Journalism) so that the information they provide is clear, accurate, and systematically
presented (e.g., foundation-supported projects that
focus on health-care reform and expansions of publicly
supported health insurance for low-income children).
A parallel effort could be undertaken to focus on EH
exposure risks to women and children.
Product labeling. For some toxicants, product labeling
has tremendous potential to change exposure; however,
the knowledge base in this area is minimal (Figure 3).
To explore how labeling can be effectively implemented
in this arena will likely require a systematic set of
research and demonstration projects.
Reexamine potential workplace interventions. An opportunity also exists for exploring with labor unions, the
Occupational Safety and Health Administration, and
occupational health professionals how improvements
might be made in relation to reproductive and perinatal health concerns in the workplace systems of toxic
risk notification and safety education. In addition, such
efforts could serve as a vehicle for promoting initiatives
to further reduce or eliminate environmental tobacco
smoke in the workplace.
Promote improved health-care provider counseling for
women and couples. Given the greater likelihood of
exposure in impoverished and/or isolated geographic
communities, the EH professional community might
consider establishing and/or strengthening partnerships with the Health Resources and Services Administration to implement targeted and vigorous outreach
to health-care providers working in area health education centers, community health centers (including
those for migrant workers), and MCH programs in
states and communities. These education and service
programs address the needs of the most vulnerable
groups (e.g., low-income, minority, immigrant, and
geographically isolated populations). They also have
strong relationships with provider organizations and
training programs, such as the National Health Service
Corps, which interface with medical professionals serving such groups.
To make up-to-date information on relevant environmental science more accessible to women’s health
providers, the organizations’ online strategies could
be replicated in the MCH professional community.
American College of Obstetricians and Gynecologists,
other MCH professional organizations (e.g., American
College of Nurse-Midwives, Association of Women’s
Health, Obstetric and Neonatal Nurses, American
Academy of Pediatrics, and American Academy of
Family Practice), and MCH-related government agencies (e.g., Maternal and Child Health Bureau, and the
Office of Women’s Health, Centers for Disease Control
and Prevention [CDC] Divisions of Perinatal Health
and Birth Defects) can feature information on EH
hazards more expansively and prominently in their
communications, including websites.
Efforts also might be made to capitalize on CDC’s
preconception health and health-care initiative and
advocate for greater attention to EH concerns. While
this initiative has acknowledged these issues, to date
relatively few EH professionals or agencies have gotten
involved in the initiative, and the issue of hazardous
environmental exposures (acute and/or chronic) has
not been a high priority.
McDiarmid and Gehle recommend that the environmental history be expanded to (1) include assessment
of environmental exposures that occur in a woman’s
home, community, or workplace and (2) present an
occupational/environmental history checklist, adapted
from work by Grajewski,65 for use by providers at the
preconception visit.56 Faucher echoes this notion.66
Information technology tools developed initially in
the pharmacy industry to assist medical care providers in examining and calculating risk in relation to
contraindications in medication might be designed
to assist in calculating environmental exposure risks,
thereby enhancing capabilities in counseling women
and their partners.
Tailoring of risk messages has moved to the forefront
in other areas of risk communication, with a number of
investigations indicating that tailoring improves communication.67,68 Tailoring was initially applied to print
communications,68 but has been used more recently
in online materials, where information is gathered
from the individual and used to create tailored messages dynamically.69 Information about a woman’s
residential and occupational environments could be
ascertained and combined with various databases to
create a uniquely tailored risk assessment and risk
communication message.
Surveillance. While systematic surveillance is available
for many reproductive and perinatal outcomes, routine
monitoring of spontaneous and induced abortions as
well as infertility faces limitations due to data availability
and quality. Birth defect registry data are available but
are not routinely monitored with regard to potential
environmental impact, nor are the levels of toxicants
monitored in correlation with birth defects or other
reproductive and perinatal outcomes.
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Reducing Exposure to Environmental Toxicants Before Birth  639
The limitations of national and local data impede
our ability to track environmental impact over time.
Further, as we seek to implement population-based
interventions to reduce maternal exposures, impact
on reproductive and perinatal health outcomes will
be difficult to ascertain without increased surveillance
of outcome indicators. In some cases (e.g., spontaneous abortions), data collection will need to expand.
Other outcomes (e.g., birth defects) may only require
increased use and monitoring of existing data.
Increased measurement and monitoring of both
toxicant biomarkers (e.g., blood levels) and selfreported exposures for pregnant women and women
of childbearing age is needed. This might be accomplished by additions to existing national surveys and
examinations, including the Pregnancy and Risk Assessment Monitoring System, the Behavioral Risk Factor
Surveillance System, the National Survey of Family
Growth, the National Survey of Children’s Health,
and the National Health and Nutrition Examination
Survey. Federal agencies could also collaborate with
OTIS and pediatric environmental health specialty
units (­PEHSUs) to systematically track data on knowledge and actions of pregnant women.
Longer-term initiatives
Create an organized system of information and care specific
to hazardous environmental exposures related to perinatal
health. Consideration should be given to creating a
more organized approach to information compilation,
dissemination, expert technical advice, and guidance
for medical education that is similar to the system used
by U.S. poison control centers (PCCs). In its recent
review of PCCs nationwide, the Institute of Medicine
noted that while there are aspects of the PCC system
that need to be strengthened, they represent a critical set of services.70 Resources that might be used and
enhanced to replicate this model in the arena of perinatal environmental risk exist, but potential impact is
hampered by (1) limited geographic coverage of the
Toxicology Information System (TIS), (2) absent or
weak linkages between the PEHSUs and TIS, and (3)
absent or weak connections with MCH programs and
with the Center for the Evaluation of Risks to Human
Reproduction health research. To be effective, such a
system needs to be very publicly visible (to assure universal access for the population and for professionals)
and should be a joint private and public health/MCH
and EH science effort. Consideration might be given
to ways in which OTIS and the PEHSU collaboration
could play a role in design and implementation.
Undertake a nationally visible and scientifically and
politically credible initiative that brings together health
and environment, with a focus on preconceptional and
prenatal toxic environmental exposures. The current state
of governmental complexity and fragmentation with
respect to research, public information, regulation, and
health services likely thwarts the natural evolution of
collaborative action in this arena. The EPA’s Prenatal
Partnership on Environmental Health has made some
progress in this regard, but certain key players have
not been present at the table; most notably, the Health
Resources and Services Administration (both the MCH
Bureau and the Bureau of Primary Care) and public
sector professionals with a major focus on MCH.
Moreover, community and state government agency
representatives should be key participants.
A report by the U.S. Surgeon General or the Institute
of Medicine may provide unifying structure and public
policy visibility. Deliberation undertaken to develop
such a report would need to include a discussion of the
role federal, state, and local agencies in MCH and EH
play with regard to protecting pregnant women from
environmentally hazardous exposures. This initiative
would work toward:
1. National shared goals;
2. A rational organization of complementary
program components for knowledge development (research), information dissemination,
consultation, and service, as well as research that
includes community-state-national linkages;
3. A prevention model that incorporates a lifespan
perspective through primary (information and
education), secondary (risk identification), and
tertiary (counseling) prevention services that
would serve as the underpinning; and
4. Communication mechanisms that link all components and strengthen accountability (including use of data/surveillance and other feedback
systems) for improved outcomes for women
and children consistent with the shared goals
articulated.
CONCLUSIONS
While the body of research informing us what pregnant
women and their providers know about environmental
toxicants and perinatal health is limited, evidence of
reproductive and perinatal toxicity has accumulated
to a point where leadership and action are necessary.
We have described a wide range of policy strategies
that could be implemented to address environmental
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640  Viewpoint
toxicants in the context of perinatal health. Effective
leadership in this area will likely require collaboration
of both EH and MCH leaders and organizations.
The authors thank Devon Payne-Sturges of the Environmental
Protection Agency (EPA) Office of Children’s Health Protection
(OCHP) and Arlene Rosenbaum of ICF International.
The authors were funded by a subcontract from ICF International, a contractor of the EPA OCHP.
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